Personnel and Parties in NTSB Aviation Accident Investigations Institute for Civil Justice • R CYNTHIA C. LEBOW • LIAM P. SARSFIELD WILLIAM L. STANLEY • EMILE ETTEDGUI • GARTH HENNING SAFETY in the SKIES SAFETY in the SKIES ii THE INSTITUTE FOR CIVIL JUSTICE The mission of the RAND Institute for Civil Justice is to improve pri- vate and public decisionmaking on civil legal issues by supplying policymakers and the public with the results of objective, empirically based, analytic research. The ICJ facilitates change in the civil justice system by analyzing trends and outcomes, identifying and evaluating policy options, and bringing together representatives of different interests to debate alternative solutions to policy problems. The Institute builds on a long tradition of RAND research characterized by an interdisciplinary, empirical approach to public policy issues and rigorous standards of quality, objectivity, and independence. ICJ research is supported by pooled grants from corporations, trade and professional associations, and individuals; by government grants and contracts; and by private foundations. The Institute dissemi- nates its work widely to the legal, business, and research communi- ties, and to the general public. In accordance with RAND policy, all Institute research products are subject to peer review before publi- cation. ICJ publications do not necessarily reflect the opinions or policies of the research sponsors or of the ICJ Board of Overseers. iii BOARD OF OVERSEERS Chair: Ronald L. Olson, Munger, Tolles & Olson Harris Ashton Sheila L. Birnbaum, Skadden, Arps, Slate, Meagher & Flom Stephen J. Brobeck, Consumer Federation of America Kim M. Brunner, State Farm Insurance Arnold I. Burns, Arnhold And S. Bleichroeder Alan F. Charles, The Institute for Civil Justice, RAND Robert A. Clifford, Clifford Law Offices N. Lee Cooper, Maynard, Cooper & Gale Gary L. Countryman, Liberty Mutual Insurance Company John J. Degnan, The Chubb Corporation Christine M. Durham, Utah Supreme Court Paul G. Flynn, Los Angeles Superior Court William B. Gould, Stanford Law School Arthur N. Greenberg, Greenberg Glusker Fields & Claman James A. Greer II Terry J. Hatter, Jr., Chief U.S. District Judge Deborah R. Hensler, Stanford Law School Patrick E. Higginbotham, United States Court of Appeals Douglas G. Houser, Bullivant Houser Bailey Roberta Katz, The Technology Network iv Safety in the Skies: Steven J. Kumble, Lincolnshire Management Mary M. McDonald, Merck & Co., Joseph D. Mandel, University of California, Los Angeles Charles W. Matthews, Exxon Corporation Arthur R. Miller, Harvard Law School Paul S. Miller, Pfizer. Robert W. Pike, Allstate Insurance Company Thomas E. Rankin, California Labor Federation, AFL-CIO Bradford W. Rich, United Services Automobile Association Robert B. Shapiro, Monsanto Company Larry S. Stewart, Stewart, Tilghman, Fox & Bianchi v PREFACE The daily movement of millions of passengers over distances thought impossible merely a century ago is emblematic of the modern trans- portation era—an era characterized by speed and personal conve- nience. The commerce of aviation, both the operation of commer- cial aircraft for profit and the development of aeronautical systems, is also an important symbol of national prestige and a powerful eco- nomic force. Safety in air transportation is, therefore, a matter of profound national importance. The National Transportation Safety Board (NTSB) plays a central role in the overall equation of aviation safety. The agency enjoys the rep- utation of being the most important independent safety investigative authority in the world; the caliber of its investigations has become the international standard. The NTSB is considered to be the best in the business and has served as a model for independent investigative authorities in many countries. However, recent major commercial aviation accidents, such as TWA Flight 800 and USAir Flight 427, have stretched the resources of the NTSB to the limit and have challenged the ability of the technical staff to unravel the kinds of complex fail- ures that led to such horrific tragedies. Preserving and enhancing the NTSB’s ability to fulfill its crucial safety mission were the central motivations for this research and are the guiding principles behind the recommendations that are proposed. Recognizing the strain now being placed upon the limited resources of the safety board and its technical staff, NTSB Chairman Jim Hall sought a self-critical examination of the agency’s capability to carry out one of its most important and visible assignments: the investi- gation of major commercial aviation accidents. Chairman Hall vi Safety in the Skies: requested that the inquiry substantially pertain to this subject, with application where appropriate to the other transportation modes under the NTSB’s jurisdiction. Although the NTSB investigates thou- sands of general aviation, marine, rail, highway, and other trans- portation accidents every year, the public reputation and credibility of the safety board substantially rest on its ability to determine the cause of major commercial aviation accidents. It is also in this area that the NTSB’s independence has been most vigorously challenged by the many stakeholders whose interests may be affected by the outcome of an investigation. In undertaking this research, RAND was able to involve personnel with expertise in several disciplines from three RAND programs: the Institute for Civil Justice, the Science and Technology Policy Insti- tute, and Project AIR FORCE. This multidisciplinary approach enabled the researchers to use a variety of quantitative and qualita- tive research techniques to examine the inner workings of the NTSB closely. This research provides the most comprehensive examina- tion of NTSB operations that has ever been undertaken in the 30-year history of the agency. We commend this report to serious consideration by the NTSB and all the affected interest groups and stakeholders involved with the investigation of major commercial aviation and other transportation accidents. The report offers significant insights into the existing investigative process and, at the same time, sets forth important rec- ommendations aimed at strengthening the safety board’s ability to carry out its essential safety mission. We believe the report makes a significant contribution to assuring the safety of the traveling public and to the advancement of public policymaking in this most impor- tant field. For information about the Institute for Civil Justice, contact Alan Charles, Director Institute for Civil Justice RAND 1700 Main Street, P.O. Box 2138 Santa Monica, CA 90407-2138 TEL: (310) 393-0411 x7803 Internet: alan_charles@rand.org Preface vii A profile of the ICJ, abstracts of its publications, and ordering infor- mation can also be found on RAND’s home page on the World Wide Web at http://www.rand.org. The full text of many ICJ publications is available online through Westlaw at http://www.westlaw.com. ix CONTENTS Preface v Figures xi Summary xiii Acknowledgments xvii Abbreviations xxi Chapter One STUDY OVERVIEW 1 A National Focus on Air Safety 3 The Role of the NTSB in Aviation Safety 4 Objectives of the Study 6 Research Approach 9 Chapter Two AIR ACCIDENT INVESTIGATION TODAY 13 Investigating a Major Commercial Aviation Accident 14 The Party Process 15 Accident Report Preparation 15 Investigating a General Aviation Accident 17 The Role of the NTSB in International Aviation Accident Investigations 17 Family Assistance and the Office of Family Affairs 18 Chapter Three STUDY FINDINGS 19 The NTSB Is Nearing the Breaking Point 23 The Party Process Has Structural Limitations 29 x Safety in the Skies Lack of Training, Equipment, and Facilities Is Threatening NTSB Independence 33 Poor Control of Information Hampers Investigations 38 Investigative Methods Need to Be Improved 39 NTSB Resources Are Not Effectively Utilized 43 Chapter Four CONCLUSIONS AND RECOMMENDATIONS 45 Conclusions 45 Recommendations 47 Strengthen the Party Process 47 Create a More Expansive Statement of Causation 49 Modernize Investigative Procedures 49 Streamline Internal Operating Procedures 51 Better Manage Resources 52 Maintain a Strategic View of Staffing 53 Streamline Training Practices 54 Improve Facilities for Engineering and Training 55 xi FIGURES 1. NTSB Budget and Staffing Levels 20 2. Workload at the NTSB’s OAS 24 3. Thirty-Year Accident History 26 4. The Growing Complexity of Transport-Category Aircraft Accidents 27 5. Dispatch Distribution for the Major Investigations Division in 1998 28 6. Notional View of Existing and Revised Party Process Models 32 7. Projected World Transport Fleet 34 8. Two Notional Views of the NTSB Training Cycle 37 9. Structuring Investigative Teams 41 [...]... area of the investigation) completes a factual report on his or her area of responsibility All factual material is placed in the public docket that is open and available for public review Thereafter, the investigators involved in the case begin an often lengthy period of further fact gathering, usually involving one or more public hearings, and final analysis of 16 Safety in the Skies the factual information... based on the findings of the investigation The safety board also provides needed technical support, such as the readout of cockpit voice recorders, to foreign investigators 18 Safety in the Skies FAMILY ASSISTANCE AND THE OFFICE OF FAMILY AFFAIRS Following the enactment of the Aviation Disaster Family Assistance Act in 1996, the President designated the NTSB as the lead federal agency for the coordination... element of the agency’s investigative process, which allows the companies and entities involved with the accident to participate directly in the NTSB investigation THE ROLE OF THE NTSB IN AVIATION SAFETY From the perspective of the NTSB, the combined effects of these successive commission and task force reports were significant, raising embraced and refined within the FAA’s... However, the safety board has no enforcement authority other than the persuasive power of its investigations and the immediacy of its recommendations In the scheme of government, the agency’s clout is unique but is contingent on the independence, timeliness, and accuracy of its factual findings and analytical conclusions Increasingly, the NTSB has no choice but to conduct its investigations in the glare... in a publicly available printed report that, barring reconsideration at a later date, is the NTSB’s final product concerning the investigation The final accident report includes a list of factual findings concerning the accident, analysis of those findings, recommendations to prevent a repetition of the accident, and a probable cause statement There is no time limit on NTSB investigative activity Safety. .. aviation safety The recommendations aim to accomplish the following eight objectives: • strengthen the party process • create a more expansive statement of causation • modernize investigative procedures • streamline internal operating procedures • better manage resources • maintain a strategic view of staffing • streamline training practices • improve facilities for engineering and training While the tenets... Scotia, killing 229 people traveling from New York to Geneva, including 137 Americans 6 Safety in the Skies operating at the limits of its capability In recent years, the NTSB has undertaken aircraft accident investigations of extraordinary cost, complexity, and length The investigation of the crash of TWA Flight 800 is still not complete, almost three-and-a-half years later The investigation of another... expanded to address hiring and workload issues In the course of the research, RAND also noted many areas in which internal NTSB practices either inhibited the hiring and training of staff, added to an already busy workload, or caused breakdowns in communication Study Overview 9 with parties involved in investigations These issues are summarized in this report The breadth of the research should also... Transportation, Washington, D.C., 1973, p 1 1 2 Safety in the Skies investigations of accidents and major incidents and, in so doing, to assure public confidence in the safety of our national transportation systems 2 The NTSB has become most publicly identified with its investigations of major commercial aviation accidents The NTSB has the responsibility for investigating every civil aviation accident in the United... Airlines had slammed into the Florida Everglades killing 110 people Their aircraft on fire and losing control, the crew struggled to land the crippled airliner The crash scene was particularly gruesome These back-to-back crashes shook the foundation of the aviation community The traveling public was frightened, and media pundits questioned the perceived safety of domestic airline operations The Clinton . EMILE ETTEDGUI • GARTH HENNING SAFETY in the SKIES SAFETY in the SKIES ii THE INSTITUTE FOR CIVIL JUSTICE The mission of the RAND Institute for Civil Justice. Washington, D.C., 1973, p. 1. 2 Safety in the Skies investigations of accidents and major incidents and, in so doing, to assure public confidence in the safety